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 Examining the Issues
Circumstances Indicating Potential for Conflict
-Abortion-
 

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1.

Introduction
Prior to 1997, the Abortion and Sterilisation Act of 1975 provided limited means whereby women in South Africa could legally procure an abortion. The number of legal Terminations of Pregnancy (TOP) approximated 500 countrywide annually but estimates in excess of 200 000 illegal abortions per year were given in part as justification for review of the law and to draw attention to the large numbers of women who would suffer, and had suffered already, the serious consequences of back street abortions if they were unable to procure one legally. With the change of government in 1994, a blueprint for a new legislation was designed to extensively liberalise the previous Act by transferring the final authority and decision to terminate the pregnancy to the woman herself (when the pregnancy was less than 12 weeks duration) and to a joint decision between herself and her doctor/midwife or social worker for pregnancies beyond 12 but less than 20 weeks. Abortions beyond this gestational age were to be permitted for exceptional reasons only.

This issue became a subject of intense national debate for the public, the body politic and the media. Public hearings were held over a number of days at the Houses of Parliament in Cape Town which gave an opportunity for interested parties to present submissions to the Portfolio Committee on Public Health. This was purported to provide valuable input from the public to the drafting of the Choice of Termination of Pregnancy Act (TOP Act) of 1996 which was formally gazetted on November 22, 1996 ¹. At least one submission drew the attention of the Committee to the problem of conscientious objection of doctors and midwives, the lack of facilities and the lack of training facilities for personnel ² . One of the features of this Draft Bill dealt with the requirement of an objecting practitioner to refer an abortion applicant to another willing colleague who would perform the TOP. Initially, this clause carried a penalty of a fine or imprisonment or both. It was subsequently removed from the final legislation after fierce opposition from represented practitioners.

Under the new Act, the Minister of Health would be granted powers to designate institutions in the country suitable for the performance of TOPs and the personnel at these institutions would be expected in the normal course of their duties to provide the full service as per the TOP Act. Only medical practitioners and trained midwives were allowed to carry out these procedures in strict accordance with the law, subject to severe penalties if they were underqualified or failed to record details of each TOP as specified in the Section 7 ¹.

The media carried details of the new legislation and the rights to be afforded to women. From 1^st February 1997, when the law was formally introduced, abortion applicants began to arrive at the designated hospitals to obtain legal TOPs. It soon became apparent that at the tertiary hospitals of the Western Cape, large numbers of State patients were referred from smaller designated facilities due to the unwillingness of personnel to do TOPs.

Eight months, following the passage of the Act, these referral patterns persisted and the number of applicants increased. In the light of this informally expressed dissatisfaction, it was decided to investigate formally the degree of compliance with the new act by doctors within our referral boundaries.
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2.

Objective
A study was designed and conducted in order to determine to what extent the doctors in the State employ at the institutions so designated by the Minister of Health, were prepared to comply with the TOP Act. From these results, appropriate recommendations could be made both internally, at a hospital level, and externally with the Department of Health as to how to accommodate doctors and the service best.

Setting
The geographical area chosen was the Western Cape primarily because this area was the referral base for Tygerberg and Groote Schuur tertiary hospitals. Fourteen secondary and fifteen primary facilities were identified. (fig 1)

Subjects
All doctors at the designated institutions (DI) in the Western Cape area who were in full or part-time State employ between 17 - 20 November 1997 and who were expected as part of their routine duties to interview, examine, counsel and perform abortions were included in this cross sectional survey. There were 308 doctors in all, comprising: specialists, registrars, medical officers (MO) and general practitioners (GP). The opinions of midwives, floor staff and anesthetic personnel were not assessed in this study.

Methods
The survey was conducted by sending a single questionnaire (figs. 2, 3) to each doctor via a contact person at the DI. This was accompanied by an explanatory letter and was enclosed with a self addressed stamped envelope for ease of return. All questionnaires were posted or hand delivered between the 17-20 November 1997. The contact person was reminded either by facsimile, or telephonically, both 2 and 3 weeks after the date of sending, to ensure that the envelopes were distributed and in turn, to remind doctors to fill them out and post them. It was decided not to use available lists of the names of doctors in the DIs and send the forms personally. This could imply that they had been identified and the risk of a poor survey return due to fear of identification was potentially serious.

The questionnaire was subjected to a pilot survey with ten doctors and three epidemiologists who screened the sections of the form for ambiguity or lack of clarity and their helpful suggestions were built into the final draft.

The questionnaire design was structured with answers able to be circled for ease of data capture, loading and interpretation.

The closing date for receiving replies was the 31^st January 1998 but it was made clear to contact personnel that the only doctors who were eligible to submit a questionnaire were those who were in the relevant posts at the time of sending.

Only one mailing would be possible as it was decided, given the controversial nature of the subject matter and the concern over victimisation, that respondents were assured that they would remain anonymous.

The results were analysed statistically using frequency tables at the Centre for Epidemiological Research of South Africa, Medical Research Council.
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